Exhibits
Which of the following findings should the nurse prioritize?
Thick green mucus
Lung sounds
The tracheostomy state
Fraction of inspired oxygen
None
None
The Correct Answer is B
Rationale:
A. Thick green mucus is important because it indicates infection and airway secretion buildup. However, while it signals the presence of pneumonia, it is not the most urgent finding to prioritize over immediate respiratory assessment. The nurse should monitor secretions and provide interventions like suctioning or hydration to help mobilize them.
B. Lung sounds are the priority. Diminished lung sounds in the right lower lobe indicate impaired ventilation and potential respiratory compromise due to pneumonia and pleural effusion. Assessing lung sounds helps the nurse determine the severity of the condition and guides urgent interventions such as oxygen therapy, suctioning, or notifying the provider for possible advanced treatment. This directly affects gas exchange and patient safety, making it the most critical finding.
C. The tracheostomy state is important for airway patency. While it must be monitored to ensure it remains patent and functional, the current notes indicate it is in place and functioning normally. Immediate intervention is not indicated unless changes occur.
D. Fraction of inspired oxygen (FiO2) is relevant to oxygen delivery. The client is currently on her usual 30% FiO2, which is appropriate for her baseline oxygenation needs. No adjustment is required unless hypoxia or respiratory distress is noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Measure pulse and blood pressure: Vital signs are the most immediate indicators of hypovolemia. A rapid pulse and hypotension can signal significant blood loss or inadequate circulating volume, allowing the nurse to detect early shock and initiate prompt interventions.
B. Observe skin elasticity: Skin turgor can provide information about fluid status, but it changes more slowly and is less sensitive than vital signs in detecting acute hypovolemia. It is supplementary to more direct hemodynamic assessments.
C. Measure urine output: Urine output is an important measure of perfusion and renal response to hypovolemia, but it reflects fluid status over a longer period and is not as immediately responsive as blood pressure and pulse.
D. Auscultate breath sounds: While monitoring for pulmonary complications is important after thoracic surgery, breath sounds do not provide direct or immediate information about circulating blood volume or hypovolemic status.
Correct Answer is C
Explanation
Rationale:
A. Comatose with no score using GCS: Even in unresponsive clients, the Glasgow Coma Scale provides a numerical score to quantify neurological status. Saying “no score” does not accurately reflect the client’s assessment and lacks standardization.
B. Unable to assess client using GCS: The GCS is designed specifically to evaluate eye, verbal, and motor responses, even in unresponsive clients. It can be fully assessed in this scenario, so it is inappropriate to document it as “unable to assess.”
C. Score of 3 on the GCS: A total GCS score of 3 represents the lowest possible score, indicating no eye opening, no verbal response, and no motor response. This score accurately reflects the client’s neurological status and is the correct documentation for an unresponsive client.
D. GCS indicates no function: While a score of 3 suggests severe neurological impairment, describing it as “no function” is vague and nonstandard. Using the numerical score ensures clear communication and allows tracking of changes over time.
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